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Auditor Bump ID’s $1.3 million in Questionable Medicaid Dental Claims

As part of an ongoing investigation into MassHealth dental provider claims, State Auditor Suzanne M. Bump today announced an audit which uncovered thousands of questionable, unallowable, and sometimes medically unnecessary claims for dental services costing the state’s Medicaid program $1.3 million. Since 2010, the Office of the State Auditor has identified $7,585,443 in total questionable Medicaid dental claims.

“I acknowledge the challenge of advancing quality dental care to underserviced populations, but audit after audit has shown that MassHealth needs to improve its screening of claims for payments from dental providers,” said Auditor Bump. “So far they have been very responsive to our reports, but in the past two and a half years, five audits reviewing just 23 providers have identified $7.4 million in improper payments. There clearly needs to be more comprehensive action taken by MassHealth to address any systemic problems that exist within its dental claims processing system.”

Test results from an audit sample of ten dental providers found over $1.2 million in questionable specialized oral exams. The procedure, referred to as a detailed oral screening, is allowable under MassHealth regulations only for members undergoing radiation treatment, chemotherapy, or organ transplant. However, these ten dental providers billed and were paid for 19,274 claims of detailed oral screenings for patients who did not meet such criteria.

$14,280 paid to two providers for unallowable fluoride treatments which exceeded recommended levels set by the American Academy of Pediatric Dentistry.

Claims for service performed by the spouse of a provider, who is a dentist but not a participating MassHealth dental provider.

MassHealth’s claims processing system, which is administered through the subcontractor DentaQuest, has been the subject of continued state audits since 2010. Because DentaQuest has not adequately monitored the dental program, it did not identify these system deficiencies. In response to audit findings, MassHealth claims DentaQuest has amended its systems to ID and refuse payment for such unallowable billings in the future.

Auditor Bump has called on MassHealth to recover all unallowable payments identified in the report, and to further investigate all detailed oral screenings for the past four fiscal years.

The Office of the State Auditor conducts technical and performance assessments of state government’s programs, departments, agencies, authorities, contracts, and vendors. With its reports, the OSA issues recommendations to improve accountability, efficiency, and transparency.